What is the workup for a patient with prolonged menstrual cramping lasting two weeks?

Workup for Menstrual Cramping Lasting Two Weeks

For menstrual cramping lasting two weeks, first rule out underlying gynecological conditions through targeted evaluation, then consider NSAIDs as first-line treatment for symptom relief. 1

Initial Evaluation

• Assess if cramping is primary dysmenorrhea (absence of pelvic pathology) or secondary dysmenorrhea (due to underlying condition) 2, 3
• Evaluate for concerning symptoms that suggest secondary causes:
  • Heavy or prolonged bleeding patterns 1
  • Irregular bleeding patterns 1
  • Pain that doesn't follow typical pattern (usually starts with bleeding and lasts 24-72 hours in primary dysmenorrhea) 4
  • Dyspareunia (painful intercourse) 3
  • Noncyclic pain 3

Physical Examination

• Complete pelvic examination to assess for:
  • Uterine size and tenderness 1
  • Cervical abnormalities 1
  • Adnexal masses or tenderness 1
  • Signs of pelvic inflammatory disease 1

Laboratory and Imaging Studies

• Pregnancy test to rule out pregnancy-related complications 1
• Complete blood count if heavy bleeding is present to assess for anemia 1
• Transvaginal ultrasound if secondary dysmenorrhea is suspected to evaluate for:
  • Fibroids 1
  • Polyps 1
  • Adenomyosis 3
  • Endometriosis (though may not be directly visualized) 2
• Consider endometrial biopsy if abnormal uterine bleeding patterns are present, particularly in older patients 1

Treatment Approach

First-line Treatment

• NSAIDs (ibuprofen 400-800 mg every 4-6 hours as needed) for 5-7 days 1, 5
  • Specifically indicated for dysmenorrhea 5
  • Target prostaglandin production, which is the primary cause of menstrual pain 4, 6
  • Begin at earliest onset of pain for maximum effectiveness 5

If NSAIDs Ineffective After 5-7 Days

• Consider hormonal treatment if medically eligible:
  • Combined hormonal contraceptives for 10-20 days 1
  • Low-dose estrogen for 10-20 days 1

If No Response After 3-6 Months

• Investigate for secondary causes of dysmenorrhea 2
• Consider referral to gynecologist for further evaluation 2
• Evaluate treatment adherence 2

Special Considerations

• Prolonged menstrual cramping (>1 week) is uncommon in primary dysmenorrhea and should raise suspicion for secondary causes 4, 3
• Endometriosis is the most common cause of secondary dysmenorrhea in adolescents and young women 2, 3
• If bleeding is heavy or prolonged along with cramping, evaluate for structural abnormalities like fibroids or polyps 1
• Persistent symptoms despite appropriate treatment warrant further investigation and possible referral 1, 2

Follow-up Recommendations

• If symptoms resolve with treatment, no immediate follow-up is necessary 1
• If symptoms persist despite treatment for 3-6 months, reevaluate for secondary causes 2
• Counsel patients to return if symptoms worsen or change in character 1
• Consider alternative contraceptive methods if current method is associated with prolonged cramping 1